Trichotillomania: finding solutions

Some years ago, I treated a woman who had been
diagnosed with trichotillomania.
This patient, who made her living as a trial attorney, had become
courtroom phobic after she began pulling the hairs out of her eyebrows
and feeling self-conscious about the awkward look of her face without
them.

She thought of penciling in eyebrows, but
instead started sending in associates to handle court appearances. Her
career was suffering, and this seemingly uncontrollable habit began to
damage her self-esteem.

As a pragmatic litigator, she approached the
problem in a specific, direct manner. “There must be a medication to
help me stop pulling out my eyebrows,” she said. Indeed, she was right. A
well-respected psychiatrist prescribed a selective serotonin reuptake
inhibitor (SSRI).

The psychiatrist theorized that the eyebrow
pulling was a compulsion disorder (not an impulse disorder, as put forth
in DSM-IV), which was the rationalization for this pharmacologic
intervention. The psychiatrist knew current evidence suggested that
medications that alter central serotonin turnover had been effective in
treating this disorder. “Concise Textbook of Clinical Psychiatry,”
Harold Kaplan and Benjamin Sadock, (Philadelphia: Lippincott Williams
& Wilkins, 1996, p. 297).

Furthermore, in this patient's history, it was
possible to identify periods of depression before the eyebrow pulling
started, if you “looked hard,” according to the treating psychiatrist.
The psychiatrist thought the patient had an underlying depression, but
she was certain, as was the patient, that this trichotillomania disorder was
causing the patient to be depressed, rather than an earlier, undiagnosed
depression.

The medication regimen and insight-oriented
psychotherapy proved to be helpful. The patient's depressed mood was
less pronounced and the eyebrow pulling behavior was reduced, but the
behavior was still occurring to the point that her eyebrows were not
growing in properly. The treating psychiatrist, realizing that she had
gone as far as she could in the treatment of the patient's trichotillomania, suggested a
different type of treatment and referred her to me for a short program
of behavior modification. The lawyer, having had a good experience in
psychotherapy, was more than eager to try something new.

For certain habit patterns, including this
patient's hair-pulling behavior, I use what I call the LPA approach,
which I developed over the years using education, emotions, relaxation,
and behavior-modification techniques. The treatment plan involves three
appointments: the Learning visit, the Philosophizing visit, and the
Action visit.

In the Learning visit we explore the issues
related to the habit on an educated, intellectual level and address
theories of how the problem might occur and the various approaches to
understanding why the person might have those behaviors.

Contributing factors include stress, anxiety,
boredom, depression, neurochemical deregulation, impoverished childhood
relationships, pathologic family relationships, the meaning of
obsessive-compulsive disorder, lifetime losses, or any other idea that
the patient might discover and name as important to her or him.

Too often, the patient is an outsider in the
treatment. In other words, the treating clinician identifies a course of
action and the patient simply complies with the treatment, many times
struggling along unknowingly. In the learning period of the LPA
approach, the patient is a partner in the treatment and is involved in
its direction.

The second part of LPA is called Philosophizing.
At this stage, we explore the unique aspects of the patient's life that
could be a direct cause of the hair pulling. This approach examines
stressors—real or imagined—that may have influenced this maladaptive
behavior. Philosophizing addresses the emotional aspect of the disorder.
We try to elicit the feelings that are occurring in the patient's life,
moving away from the learning and intellectual process. We go from
identifying past specific events to experiencing their current emotional
effects.

In the Action phase, the aim is to get a process
in place to actually alter the behavior. In the case of the attorney, I
directed her to learn how to develop a system of touching her face and
not pulling out her eyebrows. I taught her some simple relaxation
techniques, allowing her to relax and begin thinking about pleasant life
experiences and about her personality assets and strengths, including
her level of success as a professional.

As the patient began to relax, I instructed her
to move her right hand up toward her eyebrows, but to then touch her
cheek instead of pulling her eyebrows. I asked her to verbalize some of
the pleasant experiences about which she had been thinking.

By reinforcing her face-touching behavior with
positive aspects about who she is without pulling out her eyebrows, she
altered a negative experience into a positive one, both physically and
mentally. The patient had now incorporated positive feedback into the
movement. She was instructed to practice this new technique 10-15 times
per day for only 30 seconds to 1 minute, when convenient. This physical
change in the movement, coupled with a new thought process, began to
alter the habit of hair pulling.

For this patient, the approach worked. Three
months later she had a full set of eyebrows. In this partnership
approach, it is made clear that the locus of control is placed in their
hands. With this in mind, the attorney was able to independently alter
my strategy of touching the cheek with her hand. She began touching her
hands together to reinforce the non-hair pulling.

The patient remained on the SSRI, went back to
the referring psychiatrist, and continued insight-oriented
psychotherapy.

Trichotillomania
is poorly understood, and the various treatment approaches are not
consistently successful. In my experience, a combination of behavior
modification and psychopharmacology helps patients to control or
eliminate the habit. The disorder is complex, with the possibility of
multiple overlapping causes, but we still can offer treatments that
work.

Please feel free to write me at cpnews@elsevier.com
and let me know your experiences. I'll try to pass them along to our
readers.